After the tissues have been completely removed, the surgeon reattaches the remaining part of the urethra to the bladder. A cathetercatheterA flexible tube used to carry fluids into or out of the body. is placed to allow for urine to pass from the bladder while the area heals. The catheter will remain in place for 1 to 3 weeks after surgery. The PSA level should drop to very low or undetectable levels (0.2 or less) after the prostate has been removed.

There are two techniques used to surgically remove the prostate – open and laparoscopic.

Open surgical techniques

The open methods are named for where the surgeon makes the incision.

Retropubic radical prostatectomy

A retropubic radical prostatectomy is done through an incision in the lower abdomen. This surgery allows for the pelvic lymph nodes to be removed before the prostate is removed. The retropubic approach is the most common surgery for prostate cancer in Canada. It requires a hospital stay of 1 to 2 days, if there are no complications.

Perineal radical prostatectomy

A perineal radical prostatectomy is done through an incision in the area between the scrotum and the anus (the perineum) to remove the prostate gland. Some surgeons feel that this approach gives a better view of the prostate and that it is easier to reattach the urethra to the bladder.

Lymph nodes cannot be removed with the perineal approach. A separate procedure using a small incision in the abdomen may be done to remove the lymph nodes.

The hospital stay is 1 to 3 days. There is less blood loss and pain with this approach compared to the retropubic approach.

Laparoscopic surgical techniques

Laparoscopic techniques cause less blood loss and pain, and recovery from surgery is shorter.

Laparoscopic radical prostatectomy

This is a minimally invasive procedure in which several small incisions are made in the abdomen. A laparoscope and other operating instruments are inserted through these incisions to remove the prostate.

Robot-assisted laparoscopic radical prostatectomy

This newer procedure uses robotic equipment to assist the surgeon in removing the prostate.

There is little difference in the outcome for open or laparoscopic surgical methods. The results depend on the skill and experience of the surgeon rather than the type of surgery.

Nerve-sparing radical prostatectomy

Radical prostatectomy is frequently associated with erectile dysfunction. The nerves responsible for erections run in two bundles on either side of the prostate. During a radical prostatectomy, these nerves may be damaged or removed. When this happens, a man is unable to get and keep an erection firm enough to have sex (erectile dysfunction or impotence). Nerve-sparing radical prostatectomy preserves the nerve bundles and greatly reduces the occurrence of erectile dysfunction.

Nerve-sparing surgery preserves the nerve bundles while completely removing the prostate cancer. A margin of cancer-free tissue around the nerves may be left, so the nerves will continue to function normally. If the prostate cancer has grown into or around the nerves, the surgeon will not be able to save the nerves.

It is difficult for the surgeon to know before surgery if the nerves can be spared. The decision to spare nerves is made when the prostate and the tumour can be seen during surgery. Nerve-sparing surgery can be done using an open technique (retropubic or perineal approach) or laparoscopic technique (with or without robotic assistance).

Nerve-sparing surgery is more successful with early stage prostate cancer and younger, sexually active men.